Impact of a Multidisciplinary Supportive Care Model Using Distress Screening at an Asian Ambulatory Cancer Center: A Cluster Randomized Controlled Trial.

PURPOSE: The Accessible Cancer Care to Enable Support for Cancer Survivors (ACCESS) program adopts a multidisciplinary supportive care model with routine distress screening to triage newly diagnosed cancer survivors for additional support on the basis of distress levels. This study aimed to evaluate the clinical impact of ACCESS over 1 year. METHODS: We performed cluster random assignment at the oncologist level in a 1:1 ratio to receive ACCESS or usual care. Participants 21 years and older, newly diagnosed with breast or gynecologic cancer, and receiving care at National Cancer Centre Singapore were included. Outcomes assessed every 3 months for 1 year included quality of life (QoL) (primary), functioning, physical and psychological symptom burden, and activity levels. Data were analyzed using mixed-effects models. RESULTS: Participants from 16 clusters (control = 90, intervention = 83) were analyzed. The ACCESS program did not significantly improve QoL (primary outcome). However, compared with usual care recipients, ACCESS recipients reported higher physical functioning (P = .017), role functioning (P = .001), and activity levels (P < .001) at 9 months and lower psychological distress (P = .025) at 12 months. ACCESS recipients screened with high distress had poorer QoL, lower role and social functioning, and higher physical symptom distress at 3 months but had comparable scores with ACCESS recipients without high distress after 12 months. CONCLUSION: Compared with usual care, participation in the ACCESS program did not yield QoL improvement but showed earlier functioning recovery related to activities of daily living and reduced psychological distress. Routine distress screening is a promising mechanism to identify survivors with poorer health for more intensive supportive care.

Brain-derived neurotrophic factor as a biomarker in cancer-related cognitive impairment among adolescent and young adult cancer patients.

Brain-derived neurotrophic factor (BDNF) improves cognitive function by stimulating neurogenesis and neuroplasticity. We hypothesize that higher plasma BDNF levels are protective against cognitive toxicity among adolescent and young adult cancer patients (15-39 years old). In a prospective, longitudinal study, we recruited 74 newly diagnosed cancer and 118 age-matched non-cancer controls who completed the Cambridge Neuropsychological Test Automated Battery (CANTAB), Functional Assessment of Cancer Therapy-Cognitive Function questionnaire (FACT-Cog) and blood draws. Plasma BDNF was quantified using an enzyme-linked immunosorbent assay. Genomic DNA from buffy coat was genotyped for BDNF Val66Met. Most cancer participants were diagnosed with breast (24%) and head/neck (22%) cancers. After adjusting for sociodemographic variables (age, gender, race, marital status, education years), cancer participants had lower BDNF levels (ng/mL) at baseline (median: 10.7 vs 21.6, p < 0.001) and 6-months post-baseline (median: 8.2 vs 15.3, p = 0.001) compared to non-cancer controls. Through linear mixed modelling adjusted for sociodemographic variables, baseline cognition, fatigue, psychological distress, and time, we observed that among cancer participants, lower baseline BDNF levels were associated with worse attention (p = 0.029), memory (p = 0.018) and self-perceived cognitive abilities (p = 0.020) during cancer treatment. Met/Met was associated with enhanced executive function compared to Val/Val (p = 0.012). Plasma BDNF may serve as a predictive biomarker of cancer-related cognitive impairment.

Determining acceptance and perceptions of chemotherapy dose banding in an ambulatory cancer centre.

INTRODUCTION: Despite the advantages of dose banding (DB) and numerous plans to adopt this practice, uptake of DB is still poor. As opinions of healthcare professionals were deemed essential in DB's acceptance, this study surveyed key stakeholders to determine the acceptance, facilitators, and barriers of DB in chemotherapy to improve its implementation. METHODS: A cross-sectional study at the National Cancer Centre Singapore, involving physicians, nurses, and pharmacy staff, was conducted in February 2022. The Theory of Planned Behaviour was adapted to design a survey questionnaire to obtain the acceptance, facilitators, and barriers of DB. Additional questions on maximum acceptable dose variance and essential criteria for selecting drugs for DB were included. RESULTS: A total of 93 participants responded, with a mean 9.75 ± 7.37 years of clinical experience. Less than half have heard of DB while few had prior experience. Drug cost was the top selection criteria for DB, followed by toxicity, therapeutic index, frequency of use and drug wastage. Acceptance rate of DB was 41.9%, with majority agreeing to use DB in various drugs but to determine patient suitability before usage. Being greatly affected by subjective norms, having a positive outlook for DB's impacts, and no effect on toxicity significantly influenced acceptance. CONCLUSION: Prior to implementing DB at the institutional level, educational training addressing concerns over toxicity, and providing technological support can help improve acceptance. Future studies can involve patients' perspectives and more institutions for greater diversity in opinions.

Quantifying chemotherapy wastage in an ambulatory cancer centre in Singapore.

INTRODUCTION: To ensure the efficient use of chemotherapy drugs, chemotherapy wastage is an area that can be investigated. This study aims to quantify current parenteral chemotherapy wastage and estimate parenteral chemotherapy wastage when dose banding is executed, using a chemotherapy wastage calculator in an ambulatory cancer centre. The study also examines the variables that significantly predict the total cost of chemotherapy wastage, investigates the reasons for wastage, and explores opportunities to reduce wastage. METHODS: Data were collected from the pharmacy in National Cancer Centre Singapore over 9 months retrospectively. Chemotherapy wastage is the sum of wastage in the preparation phase and potential wastage in the administration phase. The calculator was created using Microsoft Excel and generated chemotherapy wastage in terms of cost and amount (mg) and analysed the reasons for potential wastage. RESULTS: The calculator reported a total of 2.22 million mg of chemotherapy wastage generated over 9 months, amounting to $2.05 million (Singapore Dollars, SGD). Regression analysis found that the cost of drug was the only independent variable that significantly predicted the total cost of chemotherapy wastage (P = 0.004). The study also identified low blood count (625 [29.06%]) as the top reason for potential wastage and no-show ($128,715.94 [15.97%]) as the reason that incurred the highest cost of potential wastage. CONCLUSION: The pharmacy has generated a considerable amount of chemotherapy wastage over 9 months. Interventions in both the preparation and administration phases are required to reduce chemotherapy wastage. The use of the chemotherapy wastage calculator in pharmacy operations could guide efforts to reduce chemotherapy wastage.

Implementing an Inclusive, Multidisciplinary Supportive Care Model to Provide Integrated Care to Breast and Gynaecological Cancer Survivors: A Case Study at an Asian Ambulatory Cancer Centre.

Introduction: Supportive care models considering inclusivity and community services to improve integrated care for cancer survivors are limited. In this case study, we described the implementation of a multidisciplinary care model employing routine distress screening and embedded integrated care pathways to integrate care across disciplines and care sectors, while remaining inclusive of the multi-ethnic and multilingual population in Singapore. We reported implementation outcomes after 18 months of implementation. Description: We reviewed the model's process indicators from September 2019 to February 2021 at the largest public ambulatory cancer centre. Outcomes assessed included penetration, fidelity to screening protocol, and feasibility in three aspects - inclusiveness of different ethnic and language groups, responsiveness to survivors reporting high distress, and types of community service referrals. Discussion/conclusion: We elucidated opportunities to promote access to community services and inclusivity. Integration of community services from tertiary settings should be systematic through mutually beneficial educational and outreach initiatives, complemented by their inclusion in integrated care pathways to encourage systematic referrals and care coordination. A hybrid approach to service delivery is crucial in ensuring inclusivity while providing flexibility towards external changes such as the COVID-19 pandemic. Future work should explore using telehealth to bolster inclusiveness and advance community care integration.

Patient satisfaction and behavioural intention in using the home medication delivery service in an ambulatory oncology centre.

BACKGROUND: The COVID-19 pandemic has increased usage of medication delivery service (MDS) significantly. MDS improves adherence to medication and clinical outcomes. OBJECTIVES: To study behavioral change factors that affect adoption of MDS, determine existing patient satisfaction level, and make recommendations to improve MDS adoption. METHODS: A single-institution, cross-sectional survey was conducted at the outpatient pharmacy of the largest ambulatory cancer centre in Singapore. The survey consisted of sections on demographics, Theory of Planned Behavior constructs and patient satisfaction questions. Descriptive analysis and logistic regression were used. RESULTS: A total of 881 patients responded. Respondents were mostly Chinese, female and subsidized patients, with a mean age of 62.4 years old. MDS use is strongly predicted by favourable attitude (OR 3.54, 95%CI 2.64-4.75; p < 0.001) and subjective norm (OR 3.07, 95%CI 2.30-4.09; p < 0.001) towards its use and greater perceived behavioral control (OR 2.48; 95%CI 1.86-3.30; p < 0.001). Being ill or frail has been identified as facilitators, while absence of face-to-face consultation and cost of delivery were barriers to the adoption of MDS. Encouragingly, the satisfaction level of our existing patients was generally high (80.2, SD16.7). Recommendation to improve MDS adoption targets facilitators and barriers identified and aims to further elevate patient satisfaction level. Establishment of a centralised pharmacy for MDS together with a call centre would be essential in the long run. CONCLUSIONS: MDS is becoming increasingly important, in line with our national strategy. Implementation of suggested short-term and long-term measures will encourage its use.

Work Outcomes and Medical Costs Among Singaporean Adolescent and Young Adult Cancer Survivors.

Purpose: To quantify and evaluate trends of work outcomes and medical costs among Singaporean adolescent and young adult (AYA) cancer survivors. Methods: This cross-sectional study was conducted at the National Cancer Centre Singapore between July 2016 and October 2018. Cancer patients who were diagnosed between the age of 15 and 39 years and had completed treatment were eligible. Siblings of cancer patients were recruited as controls. Work outcomes were collected using an investigator-designed questionnaire, while cost data were extracted from the hospital database. Descriptive statistics were used to quantify work and cost outcomes. Mixed-effects logistic regression was used to compare employment rates between survivors and controls. Generalized linear models were used to characterize trends between medical costs and symptom burden. Results: A total of 29 cancer survivors and 23 sibling controls were analyzed. Approximately 80% of survivors and controls were employed at the time of survey; however, more than half of the employed survivors reported impaired work outcomes due to effects from cancer and cancer treatment, including work reallocation, absenteeism, and decreased work ability. Median productivity loss due to absenteeism in the past 3 months was estimated to be U.S. dollar (USD) 110. Total medical cost incurred within the first year after treatment completion remained high at a median of USD6592, with out-of-pocket expenditure between 17.2% and 100.0%. Conclusion: Despite their young age and having completed cancer treatment, Singaporean AYA cancer survivors may continue to experience poor work outcomes even after resuming work. High medical costs may also persist.

Cognitive impairment in adolescent and young adult cancer patients: Pre-treatment findings of a longitudinal study.

BACKGROUND: There is little information about cancer-related cognitive impairment (CRCI) in adolescent and young adults (AYA, 15-39 years old) due to its rare incidence. Here, we present the pre-treatment (before chemotherapy or radiotherapy) evaluation of cognitive function and ability of AYA with cancer (AYAC) in a multicentered cohort study. METHODS: Newly diagnosed AYAC and age-matched healthy controls (HC) were recruited between 2018 and 2021. The primary outcome was the comparison of pre-treatment cognitive impairment defined as 2 standard deviations (SDs) below the HC on ≥1 cognitive test, or >1.5 SDs below on ≥2 tests using CANTAB® between AYAC and HC. Secondary outcomes included self-perceived cognitive ability assessed by FACT-Cog v3 and biomarkers (inflammatory cytokines and brain-derived neurotrophic factor [BDNF]). RESULTS: We recruited 74 AYAC (median age = 34) and 118 HC (median age = 32). On objective cognitive testing, we observed three times more AYAC patients performed poorly on at least 2 cognitive tests compared to HC (40.5% vs. 13.6%, p < 0.001). AYAC self-perceived less degree of cognitive impairment than HC (p < 0.001). However, AYAC perceived a greater impact of cognitive changes on their quality of life compared to HC (p = 0.039). Elevated baseline inflammatory markers (IL-2, IL-4, IL-6, IL-8, IL-10 and IFN-γ) were observed among AYAC compared to HC, and baseline BDNF was lower in AYAC compared to HC. Interaction effects between cancer diagnosis and biomarkers were observed in predicting cognitive function. CONCLUSION: With the pre-existence of CRCI and risk factors of neuroinflammation even prior to systemic therapy, AYAC should receive early rehabilitation to prevent further deterioration of cognitive function after initiation of systemic therapies. (ClinicalTrials.gov Identifier: NCT03476070).

The Impact of Statin Use and Breast Cancer Recurrence - A Retrospective Study in Singapore.

Introduction: Statins, HMG-CoA reductase inhibitors, are commonly used cholesterol-lowering medications which are also increasingly recognized to have anti-cancer properties for various cancers, including breast cancer. Most clinical evidence supports a protective effect of statin on reducing breast cancer recurrence, particularly in hormone-receptor positive breast cancers.This study seeks to study the impact of statin use on breast cancer recurrence in an Asian population. Methods: This is a retrospective study of patients diagnosed with breast cancer at the National Cancer Centre and Singapore General Hospital from 2005-2015. Statin use was defined as use after surgery. Associations between statin use, breast cancer recurrence and overall survival were estimated using Cox proportional hazards regression with adjustment for age, TNM stage, grade, ER/HER2 status, and co-morbidities. Associations between statin-use and disease-specific survival were estimated using competing risks regression. Results: A total of 7858 females with breast cancer were studied, 1353(17.2%) were statin users, 6505(82.8%) were non-statin users, with a median follow-up of 8.67 years. Distribution of cancer stage, histology, molecular subtypes and grades were similar in both groups. Estrogen receptor(ER) positive (HR 0.57,95%CI 0.43-0.76,p<0.001) and HER2 negative (HR 0.74,95%CI 0.57-0.96,p=0.026) invasive cancers had a lower risk of recurrence in statin users. Statin users trended towards a long term recurrence-risk reduction (all subtypes,HR 0.48,p=0.002; ER-, HR 0.34,p=0.036; HER2+,HR 0.10,p=0.002). The risk-reduction benefit is not appreciated in statin users with DCIS, possibly due to small recurrence event numbers. Disease-specific survival benefit was seen in statin users with ER+ cancers (adjusted SHR 0.71,95%CI 0.53-0.96,p=0.027), especially ER+ invasive cancers (adjusted SHR 0.72, 95%CI 0.53-0.97,p=0.028), but with no statistically significant benefit in overall survival for statin users (all subtypes). Conclusion: This is the first known retrospective study on the effect of statin use and breast cancer recurrence in an Asian population. Similar to previous international studies, statin use is associated with a risk reduction in breast cancer recurrence. This is especially beneficial in patients who have ER+ and HER2- invasive breast cancer. Statin use is also associated with a reduced risk of breast cancer recurrence in all subtypes of breast cancer in the long term (>6 years post diagnosis).

Investigating how cancer-related symptoms influence work outcomes among cancer survivors: a systematic review.

PURPOSE: The purpose of this study is to investigate how different cancer-related symptoms influence work outcomes among cancer survivors. METHODS: A literature search was performed in PubMed, EMBASE, CINAHL, PsycINFO, and Scopus to identify studies published between 1st January 1999 and 30th October 2020 that investigated the impact of specific cancer-related symptoms on work outcomes among cancer survivors who have completed primary antineoplastic treatment. Study findings were extracted and grouped by symptoms and work outcomes, allowing comparison of associations between these outcomes. RESULTS: Seventy-three articles representing 68 studies were eligible for inclusion. From these studies, 27 cancer-related symptoms, 9 work outcomes, and 68 unique associations between specific symptoms and work outcomes were identified. Work status (return to work and employment rates) was most commonly studied, and symptom burden was mainly measured from the patient's perspective. Higher symptom burden was generally associated with trends of poorer work outcomes. Significant associations were reported in most studies evaluating body image issues and work status, oral dysfunction and work status, fatigue and work ability, and depression and work ability. CONCLUSION: Several cancer-related symptoms were consistently associated with inferior work outcomes among cancer survivors. Body image issues and oral dysfunction were shown to be associated with poorer employment rates, while fatigue and depression were linked to lower levels of work performance. IMPLICATIONS FOR CANCER SURVIVORS: Failure to return to work and decreased productivity post-cancer treatment can have negative consequences for cancer survivors and society at large. Findings from this review will guide the development of work rehabilitation programs for cancer survivors. PROTOCOL REGISTRATION: PROSPERO identifier CRD42020187754.

Early Outcomes of a National Cancer Center's Strategy Against COVID-19 Executed Through a Disease Outbreak Response Taskforce.

PURPOSE: We present the strategy of a comprehensive cancer center organized to make operations pandemic proof and achieve continuity of cancer care during the COVID-19 pandemic. METHODS: Disease Outbreak Response (DORS) measures implemented at our center and its satellite clinics included strict infection prevention, manpower preservation, prudent resource allocation, and adaptation of standard-of-care treatments. Critical day-to-day clinical operations, number of persons screened before entry, staff temperature monitoring, and personal protection equipment stockpile were reviewed as a dashboard at daily DORS taskforce huddles. Polymerase chain reaction swab tests performed for patients and staff who met defined criteria for testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were tracked. Descriptive statistics of outpatient attendances and treatment caseloads from February 3 to May 23, 2020, were compared with the corresponding period in 2019. RESULTS: We performed COVID-19 swabs for 80 patients and 93 staff, detecting three cancer patients with community-acquired COVID-19 infections with no nosocomial transmission. Patients who required chemotherapy, radiotherapy, or surgery and patients who are on maintenance treatment continued to receive timely treatment without disruption. The number of intravenous chemotherapy treatments was maintained at 97.8% compared with 2019, whereas that of weekly radiotherapy treatments remained stable since December 2019. All cancer-related surgeries proceeded without delay, with a 0.3% increase in workload. Surveillance follow-ups were conducted via teleconsultation, accounting for a 30.7% decrease in total face-to-face clinic consultations. CONCLUSION: Through the coordinated efforts of a DORS taskforce, it is possible to avoid nosocomial SARS-CoV-2 transmissions among patients and staff without compromising on care delivery at a national cancer center.

A study protocol for HEalth-Related quality of life-intervention in survivors of Breast and other cancers experiencing cancer-related fatigue using TraditionAL Chinese Medicine: the HERBAL trial.

BACKGROUND: Cancer-related fatigue (CRF) is a debilitating condition which commonly affects cancer survivors. The management of CRF remains a challenge due to the lack of effective pharmacological interventions. Traditional Chinese medicine (TCM) could be a potential therapeutic option for CRF. The modified Xiang Bei Yang Rong Tang (XBYRT) is a TCM herbal decoction, formulated to improve fatigue symptoms in cancer survivors. This clinical trial aims to evaluate the efficacy and safety of XBYRT in improving CRF and quality of life (QOL) of cancer survivors. METHODS: This is a single centre, randomized, double-blind, placebo-controlled, parallel trial. Eighty cancer survivors will be recruited and randomized to receive the XBYRT or placebo decoction, in a ratio of 1:1. Participants will consume the XBYRT/placebo decoction daily for 8 weeks and undergo assessments at baseline and 4, 8 and 10 weeks after baseline. The participants will be assessed for patient-reported outcomes (PRO), blood biomarkers and adverse events at each time point. The primary outcome is the overall health and QOL status, at 8 weeks follow-up. The secondary outcomes are the effects of XBYRT on fatigue levels, cancer-related cognitive impairment and QOL, as assessed by PRO. The incidence of adverse events and the effects of the XBYRT decoction on blood biomarkers associated with CRF will also be evaluated. DISCUSSION: Efficacy and safety outcomes from this trial will provide important clinical data to guide future large-scale randomized controlled trials, and the evaluation of the objective blood biomarkers can help to delineate the biological mechanisms of CRF. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT04104113 . Registered on 26 September 2019.

A Study of Medication Use of Cancer and Non-Cancer Patients in Home Hospice Care in Singapore: A Retrospective Study from 2011 to 2015.

Background: In recent years, there has been a rising demand for home hospice care in Singapore and globally. Studies have shown that polypharmacy and the use of potentially inappropriate medications (PIMs) remain prevalent in palliative care patients. This is commonly associated with increased adverse drug reactions and hospitalization. However, research on medication use in hospice care and its appropriateness is lacking in Asian settings. Objective: (1) To describe the medication use among cancer and non-cancer patients in home hospice care settings in Singapore at two time points, on the day of referral and at death. (2) To describe the discontinuation patterns of medications and assess their appropriateness. Design: This retrospective study analyzed 6158 cancer and 780 non-cancer cases referred to HCA Hospice Care (HCA), Singapore. Sociodemographic, clinical, and medication data were extracted from electronic medical records. The OncPal Deprescribing Guideline (OncPal) was utilized to assess the appropriateness of discontinuation of medications. Results: Non-cancer patients had a higher mean number of medications at admission and death, with 7.84 and 7.07 medications, respectively (p < 0.05), compared with cancer patients, with 5.65 and 5.69 medications, respectively (p = 0.372). The top medications for all patients were laxatives, opioids, and proton pump inhibitors (PPIs). These were mainly used for symptom control. PPI was the main PIM identified by OncPal. Conclusion: Despite being close to end of life and on hospice care, majority of patients still experienced significant medication burden. Continuous assessment of PIMs for their appropriateness based on clinical indications is imperative to reduce polypharmacy.

Design Considerations in the Development of App-Based Oral Anticancer Medication Management Systems: a Qualitative Evaluation of Pharmacists' and Patients' Perspectives.

Smartphone apps can potentially help in enhancing oral anticancer medication (OAM) adherence. Patient adoption and efficacy of such apps depends on inclusion of user-centred and evidence-based features. The objective of this study was to identify important design considerations from the perspectives of patients taking OAMs, caregivers and oncology pharmacists. The study employed a qualitative study design. Data were collected using in-depth interviews with patients (n = 15), caregivers (n = 3) and pharmacists (n = 16). Interviews were audio-recorded, transcribed verbatim and inductive thematic analysis approach was used in data analysis. Monitoring medication-related problems, medication information, replacement of or integration with current systems and accessibility of app content on devices other than smartphones were the key themes identified in the analysis. Flexible input methods for monitored data, glanceability of monitored reports/information, near real-time adherence enhancing and symptom management interventions and customisable reminder options were design considerations identified under the monitoring medication-related problems theme. Participants suggested the provision of focused and easily understandable medication information with a potential for personalisation. Integration of app-based adherence systems with patients' electronic medical records with added mechanisms for alerts in the dispensing system was also suggested as a key design requirement to improve quality of patient care and facilitate adoption by clinicians. Finally, smartphones were the most favoured platform with optional accessibility of app content on other devices. In conclusion, important design considerations were identified through a user-centred design approach. The findings will help developers and clinicians in the design of new app-based systems and evaluation of existing ones.

User acceptance of an app-based adherence intervention: Perspectives from patients taking oral anticancer medications.

BACKGROUND: Widespread adoption by patients is imperative for the success of app-based interventions for enhancing adherence to oral anticancer medications. Patients' attitudes and beliefs should be evaluated to understand determinants of their acceptance and adoption of such interventions. OBJECTIVE: To identify factors that influence cancer patients' intention to adopt an app-based system for enhancing oral anticancer medication adherence. METHODS: This study was conducted as part of the usability evaluation of an app-based system for enhancing adherence. We followed the grounded theory approach employing audio-recorded face-to-face interviews for data collection from patients taking oral anticancer medications (n = 15) and caregivers of such patients (n = 3). Data analysis involved verbatim transcription of all interviews, coding of the transcripts and field notes, detailed memo writing, and constant comparative evaluation of emergent categories. RESULTS: A conceptual framework of facilitating and hindering factors for users' adoption intention for an oral anticancer medication adherence app was developed. Findings suggest that facing difficulties in maintaining adherence and patients' perceived superiority of the app over their current methods facilitate adoption intention. In contrast, having to pay, lack of language options and users' perception of low competence in using an app were the hindrance factors. CONCLUSION: This study showed that adoption of adherence apps could be explained by technology acceptance constructs, such as performance expectancy. Adoption intention was also facilitated by patients perceived vulnerabilities in maintaining adherence to their medications, which was a health behaviour construct. Implementation of app-based programs should address patients' perceived vulnerabilities and relative advantage of the app over their current methods. Clinicians and app developers should also consider the financial, technological and language barriers for end users.

Prevalence and Risk of Polypharmacy Among Elderly Cancer Patients Receiving Chemotherapy in Ambulatory Oncology Setting.

PURPOSE OF REVIEW: This was a single center, retrospective cross-sectional study looking into the incidence and types of drug-related problems (DRPs) detected among elderly cancer patients receiving at least three long-term medications concurrent with IV chemotherapy, and the types of intervention taken to address these DRPs. This paper serves to elucidate the prevalence and risk of polypharmacy in our geriatric oncology population in an ambulatory care setting, to raise awareness on this growing issue and to encourage more resource allocation to address this healthcare phenomenon. RECENT FINDINGS: DRP was detected in 77.6% of elderly cancer patients receiving at least three long-term medications concurrent with IV chemotherapy, with an average incidence of three DRPs per patient. Approximately half of DRPs were related to long-term medications. Forty percent of DRPs required interventions at the prescriber level. The use of five or more medications was shown to almost double the risk of DRP occurrence (OR 1.862, P = 0.039). Out of the eight predefined categories of DRPs, underprescribing was the most common (26.7%), followed by adverse drug reaction (25.0%) and drug non-adherence (16.2%). Polypharmacy leading to DRPs is a common occurrence in elderly cancer patients receiving outpatient IV chemotherapy. There should be systematic measures in place to identify patients who are at greater risk of inappropriate polypharmacy and DRPs, and hence more frequent drug therapy optimization and monitoring. The identification of DRPs is an important step to circumvent serious drug-related harm. Future healthcare interventions directed at reducing DRPs should aim to assess the clinical and economic impact of such interventions.

Patients' Perception of App-based Educational and Behavioural Interventions for Enhancing Oral Anticancer Medication Adherence.

Well-designed smartphone apps can potentially help in enhancing adherence to oral anticancer medications (OAMs). The objective of this study was to evaluate patients' perception on inclusion of various adherence-enhancing strategies as features of an app and their interest in using such app. A cross-sectional survey was conducted at the National Cancer Centre Singapore. A structured self-administered questionnaire was used to collect data from patients taking OAMs. Final analysis was based on 409 surveys and most of the respondents were female (291, 71.1%), Chinese (332, 81.2%), married (296, 72.4%) and breast cancer patients (211, 51.6%). Close to two-thirds of respondents rated medication information (65.0%), disease information (60.2%) and side effect self-management (60.2%) features as having the highest level of importance in an adherence app. Three hundred thirty-two (81.2%) of the respondents owned a smartphone, among which 92 (27.7%) reported using health-related apps. From respondents with smartphones, 219 (66.0%) were interested in using an app for OAM adherence. Age 65 and older compared to 21-54 years old (adjusted OR = 0.34; 95% CI = 0.15-0.76) and current use of a health app (adjusted OR = 1.91; 95% CI = 1.07-3.41) were significant predictors of interest to adopt an adherence app. In conclusion, patients value the inclusion of educational and behavioural interventions in adherence apps. Developers of adherence apps should consider including tools for side effect self-management and provision of information to educate patients on their medications and disease condition.

Prevalence and Determinants of Adherence to Oral Adjuvant Endocrine Therapy among Breast Cancer Patients in Singapore.

OBJECTIVE: The success of oral adjuvant endocrine therapy (OAET) is greatly influenced by patients' level of adherence to treatment. The objective of this study is to measure the prevalence and determinants of adherence to OAET among breast cancer patients in Singapore. METHODS: A cross-sectional survey of patients supplemented by analysis of their prescription records was used to collect data. Adherence to OAET was assessed using the Morisky Medication Adherence Scale-4 items and evaluation of refill gaps. Univariate and multivariate analyses were done to evaluate the association between patients' characteristics and adherence to OAET. RESULTS: A total of 157 women who have started OAET at least 6 months before the time of interview participated in the study, of which less than half (64 patients, 40.8%) of the patients had high adherence. Univariate analysis identified patients who were 57 years or older (P = 0.027), unemployed (P = 0.027), on aromatase inhibitors (P = 0.023), on three or more concurrent medications (P = 0.001), and had one or more comorbidities (P = 0.000) to be significantly more adherent. However, only the number of comorbidities was found to be an independent predictor of adherence in a multiple logistic regression analysis (adjusted odds ratio = 2.60; 95% confidence interval = 1.208-5.593; P = 0.015). Forgetfulness was the main reason for nonadherence mentioned by 63 (67.7%) of the 93 nonadherent patients. CONCLUSIONS: Low level of OAET adherence was found in this study, and forgetfulness was cited as the main reason for nonadherence. Patients were generally receptive to the implementation of various strategies to assist them with their medication-taking behavior.

Drug-related problems in elderly patients with cancer receiving outpatient chemotherapy.

PURPOSE: This study aimed to identify common drug-related problems(s) (DRP) among elderly patients receiving outpatient chemotherapy, common drugs involved, and common actions taken to resolve key DRP detected. METHODS: A retrospective study was conducted at the National Cancer Centre Singapore (NCCS). Elderly patients (aged≥65) with any cancer type and stage, taking at least 3 chronic medications, and who received medication therapy management (MTM) between January 2011 and December 2012 were included in the study. RESULTS: Two hundred ninety-four patients were included in the final analysis. The mean age of the patients was 71.8 years. The patients had a median of 3 co-morbid conditions and were taking a median of 6 chronic medications. The common DRP detected were potential drug interactions (DDI) (398 cases, 36.4%), adverse drug events (346 cases, 31.7%), and non-adherence (97 cases, 8.9%). Majority of potential DDI detected involved non-chemotherapeutic agents (369 cases, 92.7%) and monitoring of patient was the most common action taken (316 cases, 79.4%). Adverse drug events detected were mostly associated with chemotherapy (316 cases, 91.3%) and patient education was the most common action taken (236 cases, 68.2%). Non-adherence in patients was commonly resolved by patient education (59 cases, 60.8%). Only 5 or more chronic medications taken were found to be associated with the presence of DRP in multivariate analysis (p≤0.05). CONCLUSION: Greater understanding of DRP will enable early detection and appropriate management of DRP, thereby improving patient care for elderly patients with cancer.

Trajectory and risk factors for chemotherapy-induced nausea and vomiting in Asian patients with head and neck cancer.

BACKGROUND: The purpose of this study was to analyze the trajectory of and risk factors for chemotherapy-induced nausea and vomiting in Asian patients with head and neck cancer. METHODS: Adult patients with head and neck cancer scheduled to receive cisplatin-based chemotherapy were recruited for the study. Clinical events were collated from standardized diaries. RESULTS: Two hundred thirty-five patients were included in the analyses. The majority (75.7%) was men, Chinese (81.7%), and manifested nasopharyngeal cancer (83.4%). The overall incidence of significant nausea and vomiting was 73.7% and 24.7%, respectively, with single-day cisplatin regimens of 48.9% and 28.9%, respectively, with the multiple-day cisplatin regimen. Patients using complementary alternative medicine were less likely than others to achieve a complete response to antiemetics. CONCLUSION: Although postchemotherapy vomiting is relatively well controlled in Asian patients with head and neck cancer, postchemotherapy nausea remains problematic in this population.